LETTERS LEARNING GOALS MAY PREVENT “GOALS GONE WILD” The recent special issue describes complex problems challenging the Veterans Health Administration.1,2 Complex problems require thoughtful, realistic solutions, but such solutions may be difficult to develop in environments that value short-term, goal-focused performance. Currently, the Veterans Health Administration faces accusations of inappropriate scheduling practices that delayed or prevented care. Unrealistic performance standards are one potential cause.3 Health care leaders should consider the potential unintended impact of performance incentives on risk taking and unethical behavior, colloquially known as “goals gone wild.”4 Learning goals may be one solution. Goal setting is a well-researched, effective intervention.5 Goals are powerful motivators that may be strengthened by incentives.6 Experimental studies demonstrate that specific, difficult goals improve task performance.7,8 Specific goals focus attention and difficult goals motivate effort. Effects are strongest for simple tasks, in part because solutions to complex tasks require more than just increased effort.9 We propose a focus on learning goals instead of performance goals as a solution to complex

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problems, such as suicidal ideation, homelessness, and population health identified in the special issue. The distinction between performance and learning goals reflects the difference between means and ends. Performance goals are appropriate when strategies for achieving a goal (i.e., the means) are well known but there is a need to increase either motivation or attention toward achieving the goal (i.e., the ends). For example, performance goals are appropriate for increasing motivation and attention toward providing aspirin for possible acute myocardial infarction. Implementing performance goals for complex public health challenges may result in undesirable side effects, such as increased risk taking and unethical behavior because performance goals overly focus attention on personally relevant rewards and punishments.10 This may limit individuals’ ability to consider broader implications of goal-focused behavior, such as effective and ethical solutions to complex problems. Learning goals focus attention on developing new means to achieve the ends.4,10 In practice, facilities that demonstrate progress in developing strategies that are innovative for difficult, complex problems such as access, suicide, homelessness, and population health could be rewarded regardless of whether the strategies are initially effective. For example, a facility could be rewarded based on the degree to which it developed and tested a thoughtful strategy for increasing access. The reward would be based on the degree of incremental learning resulting from the program. Such a learning strategy would take pressure off leaders to be perceived as successful and focus effort where it belongs—improving care. j Justin K. Benzer, PhD Suzannah K. Creech, PhD David C. Mohr, PhD Martin P. Charns, DBA

About the Authors Justin K. Benzer, David C. Mohr, and Martin P. Charns are with the Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), and the Department of Health Policy and Management, Boston University School of Public Health,

December 2014, Vol 104, No. 12 | American Journal of Public Health

Boston, MA. Suzannah K. Creech is with the Vulnerable Veteran Populations Research group, Providence VA Medical Center, and the Department of Psychiatry, Warren Alpert Medical School of Brown University, Providence, RI. Correspondence should be sent to Justin K. Benzer, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, 150 S. Huntington Ave (152-M), Boston, MA 02130, USA, 857-364-5691 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted August 10, 2014. doi:10.2105/AJPH.2014.302264

Contributors The letter was conceptualized by J. K. Benzer and S. K. Creech. D. C. Mohr and M. P. Charns contributed to the writing and conceptual development.

Acknowledgments This material is based upon work supported by the Department of Veterans Affairs, VA Health Services Research and Development Career Development Award (CDA 11-246). Note. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government. Funders did not influence the collection, analysis, and interpretation of the data, or the preparation, review, or approval of the article.

References 1. Clancy CM, Uchendu US, Jones KT. Excellence and equality in health care. Am J Public Health. 2014;104 (suppl 4):S527---S528. 2. Atkins D, Kilbourne A, Lipson L. Health equity research in the Veterans Health Administration: we’ve come far but aren’t there yet. Am J Public Health. 2014;104(suppl 4):S525---S526. 3. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014;371(4):295---297. 4. Ordóñez LD, Schweitzer ME, Galinsky AD, Bazerman MH. Goals gone wild: The systematic side effects of overprescribing goal setting. Acad Manag Perspect. 2009;23(1):6---16. 5. Locke EA, Latham GP. Building a practically useful theory of goal setting and task motivation: A 35-year odyssey. Am Psychol. 2002;57(9):705---717. 6. Guzzo RA, Jette RD, Katzell RA. The effects of psychologically based intervention programs on worker productivity: a meta-analysis. Person Psychol. 1985;38(2):275-- 291. 7. Tubbs ME. Goal setting: a meta-analytic examination of the empirical evidence. J Appl Psychol. 1986;71(3):474-- 483. 8. Mento AJ, Steel RP, Karren RJ. A meta-analytic study of the effects of goal setting on task performance: 1966--1984. Organ Behav Hum Decis Process. 1987;39(1):52---83. 9. Wood RE, Mento AJ, Locke EA. Task complexity as a moderator of goal effects: a meta-analysis. J Appl Psychol. 1987;72(3):416---425. 10. Barsky A. Understanding the ethical cost of organizational goal-setting: a review and theory development. J Bus Ethics. 2008;81(1):63---81.

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